SINDROM KORONER AKUT

(LK 3b)
 Scope of Problem
(2004 stats)
• CHD single leading cause of
death in United States
– 452,327 deaths in the U.S. in 2004

• 1,200,000 new & recurrent

coronary attacks per year

• 38% of those who with

coronary attack die within a
year of having it

• Annual cost > $300 billion

 Definitions
• Acute coronary syndrome is defined as
myocardial ischemia due to myocardial
infarction (NSTEMI or STEMI) or unstable
angina
• Unstable angina is defined as angina at rest,
new onset exertional angina (<2 months),
recent acceleration of angina (<2 months), or
post revascularization angina
Conditions that may mimic ACS include:

• Musculoskeletal chest pain

• Pericarditis (can have acute ST changes)
• Aortic dissection
• Central Nervous System Disease (may mimic
MI by causing diffuse ST-T wave changes)
• Pancreatitis/Cholecystitis
 Expanding Risk Factors
• Smoking
• Hypertension
• Diabetes Mellitus
• Dyslipidemia
– Low HDL < 40
– Elevated LDL / TG
• Family History—event in
first degree relative >55
male/65 female
 Age-- > 45 for male/55
for female
 Chronic Kidney Disease
 Lack of regular physical
activity
 Obesity
 Lack of diet rich in fruit,
veggies, fiber
Atherogenesis and Atherothrombosis:
A Progressive Process
Plaque
Athero- Rupture/ Myocardial
Fatty Fibrous sclerotic Fissure &
Normal Streak Plaque Plaque Thrombosis Infarction

Ischemic
Stroke

Critical
Leg
Clinically Silent Angina
Ischemia
Transient Ischemic Attack
Claudication/PAD
Cardiovascular Death
Increasing Age

3
 Thrombus forms and
Unstable coronary extends into the lumen
artery disease

Thrombus

Lipid core

Adventitia
 RISK FACTORS FOR PLAQUE RUPTURE
Local Factors Systemic Factors
Cap Smoking
Fatigue
Cholesterol
Atheromatous Core
(size/consistency)
Diabetes
Mellitus Fibrinogen
Cap
Thickness/
Consistency
Cap Homocysteine
Impaired
Inflammation
Fibrinolysis

Plaque
Rupture

Fuster V, et al. N Engl J Med. 1992;326:310-318.

Falk E, et al. Circulation. 1995:92:657-671.
 Acute Coronary Syndromes
• Unstable Angina
Similar pathophysiology
• Non-ST-Segment
Elevation MI Similar presentation and
(NSTEMI) early management rules

STEMI requires evaluation

• ST-Segment Elevation for acute reperfusion
MI (STEMI) intervention
 Diagnosis of Angina
• Typical angina—All three of the following
• Substernal chest discomfort
• Onset with exertion or emotional stress
• Relief with rest or nitroglycerin

• Atypical angina
• 2 of the above criteria

• Noncardiac chest pain

• 1 of the above
 Diagnosis of Acute MI
STEMI / NSTEMI

• At least 2 of the following

• Ischemic symptoms
• Diagnostic ECG
changes
• Serum cardiac marker
elevations
 CONSEQUENCES OF CORONARY THROMBUS
CORONARY THROMBUS

Small thrombus Partially occlusive Occlusive

(non-flow limiting) thrombus thrombus
Transient
ischemia Prolonged
ischemia
No ECG
changes ST segment
Depression and/or ST elevation
T wave inversion (Q wave later)

Healing and
Plaque enlargement Negative
Serum Positive Positive
biomarkers Serum Serum
biomarkers biomarkers

UNSTABLE NON-ST SEGEMENT ST SEGMENT

ANGINA ELEVATION ELEVATION
 The Three I’s
• Ischemia= ST depression or T-wave inversion
Represents lack of oxygen to myocardial tissue
 The Three I’s
• Injury = ST elevation -- represents prolonged
ischemia; significant when > 1 mm above the baseline
of the segment in two or more leads
 The Three I’s
• Infarct = Q wave — represented by first
negative deflection after P wave; must be
pathological to indicate MI
Unstable
Angina NSTEMI STEMI

Occluding thrombus Complete thrombus

Non occlusive sufficient to cause occlusion
thrombus tissue damage & mild
myocardial necrosis ST elevations on
Non specific ECG or new LBBB
ECG ST depression +/-
T wave inversion on Elevated cardiac
Normal cardiac ECG enzymes
enzymes
Elevated cardiac More severe
enzymes symptoms
Acute Management

• Initial evaluation &

stabilization

• Efficient risk
stratification

• Focused cardiac care

 Evaluation
• Efficient & direct history
Occurs
• Initiate stabilization interventions simultaneously

Plan for moving rapidly to

indicated cardiac care
Directed Therapies
are
Time Sensitive!
 Chest pain suggestive of ischemia

Immediate assessment within 10 Minutes

Initial labs Emergent History &
and tests care Physical
– 12 lead ECG  IV access  Establish

– Obtain initial  Cardiac diagnosis

cardiac enzymes monitoring  Read ECG
– electrolytes, cbc  Oxygen  Identify
lipids, bun/cr,  Aspirin complications
glucose, coags
 Nitrates  Assess for
– CXR reperfusion
 Focused History
• Aid in diagnosis and • Reperfusion questions
rule out other causes
– Timing of presentation
– Palliative/Provocative
– ECG c/w STEMI
factors
– Contraindication to
– Quality of discomfort
fibrinolysis
– Radiation
– Degree of STEMI risk
– Symptoms associated
with discomfort
– Cardiac risk factors
– Past medical history -
especially cardiac
 Targeted Physical
• Examination • Recognize factors that
– Vitals increase risk
– Cardiovascular • Hypotension
system • Tachycardia
– Respiratory system • Pulmonary rales, JVD ↑,
– Abdomen pulmonary edema,
– Neurological status • New murmurs/heart
sounds
• Diminished peripheral
pulses
• Signs of stroke
 ECG assessment

ST Elevation or new LBBB

STEMI

ST Depression or dynamic
T wave inversions
NSTEMI

Non-specific ECG
Unstable Angina
Lokasi infark berdasarkan letak perubahan
gambaran EKG

Anterior : V1-V6
Anteroseptal : V1-V4
Anterior ekstensif : V1-V6, I-AVL
Inferior : II, III, AVF
Lateral : I, AVL, V5-V6
Posterior : V7-V9
Ventrikel Kanan : V3R-V4R
Normal or non-diagnostic EKG
ST Depression or Dynamic T wave
Inversions
ST-Segment Elevation MI
 New LBBB

QRS > 0.12 sec

L Axis deviation
Prominent Q wave V1-V3
Prominent S wave 1, aVL, V5-V6
with T-wave inversion
 Cardiac markers
• Troponin ( T, I) • CK-MB isoenzyme
– Very specific and more – Rises 4-6 hours after injury
sensitive than CK and peaks at 24 hours
– Rises 4-8 hours after – Remains elevated 36-48
injury hours
– May remain elevated for – Positive if CK/MB > 5% of
up to two weeks total CK and 2 times
– Can provide prognostic normal
information – Elevation can be predictive
– Troponin T may be of mortality
elevated with renal dz, – False positives with
poly/dermatomyositis exercise, trauma, muscle
dz, DM, PE
 Risk Stratification
Based on initial
Evaluation, ECG, and
Cardiac markers
STEMI
Patient?
YES NO

- Assess for reperfusion UA or NSTEMI

- Select & implement - Evaluate for Invasive vs.
reperfusion therapy conservative treatment
- Directed medical therapy - Directed medical
therapy
 Cardiac Care Goals

• Decrease amount of myocardial necrosis

• Preserve LV function
• Prevent major adverse cardiac events
• Treat life threatening complications
 Tatalaksana Pra Rumah Sakit
Petugas kesehatan/dokter umum di klinik
- Mengenali gejala sindrom koroner akut dan pemeriksaan EKG bila ada
- Tirah baring dan pemberian oksigen 2-4 L/menit
- Berikan aspirin 160-325 mg tablet kunyah bila tidak ada riwayat
alergi aspirin
- Berikan preparat nitrat sublingual misalnya isosorbid dinitrat 5 mg
dapat diulang setiap 5-15 menit sampai 3 kali
- Bila memungkinkan pasang jalur infus
- Segera kirim ke rumah sakit terdekat dengan fasilitas ICCU (Intensive
Coronary Care Unit) yang memadai dengan pemasangan oksigen dan
didampingi
dokter/paramedik yang terlatih
 STEMI cardiac care
• STEP 1: Assessment
– Time since onset of symptoms
– 90 min for PCI / 12 hours for fibrinolysis

– Is this high risk STEMI?

– KILLIP classification
– If higher risk may manage with more invasive rx

– Determine if fibrinolysis candidate

– Meets criteria with no contraindications

– Determine if PCI candidate

– Based on availability and time to balloon rx
 Fibrinolysis Indications

• ST segment elevation >1mm in two

contiguous leads
• New LBBB
• Symptoms consistent with ischemia
• Symptom onset less than 12 hrs prior to
presentation
 Absolute contraindications for fibrinolysis therapy in
patients with acute STEMI

• Any prior Intra Cranial Haemoragic

• Known structural cerebral vascular lesion
• Known malignant intracranial neoplasm (primary
or metastatic)
• Ischemic stroke within 3 months EXCEPT acute ischemic
stroke within 3 hours
• Suspected aortic dissection
• Active bleeding or bleeding diathesis (excluding menses)
• Significant closed-head or facial trauma within 3 months
 Relative contraindications for fibrinolysis therapy in
patients with acute STEMI
• History of chronic, severe, poorly controlled hypertension
• Severe uncontrolled hypertension on presentation (SBP greater than 180
mm Hg or DBP greater than 110 mmHg)
• History of prior ischemic stroke greater than 3 months, dementia, or known
intracranial pathology not covered in contraindications
• Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less
than 3 weeks)
• Recent (within 2-4 weeks) internal bleeding
• Noncompressible vascular punctures
• For streptokinase/anistreplase: prior exposure (more than 5 days ago) or
prior allergic reaction to these agents
• Pregnancy
• Active peptic ulcer
• Current use of anticoagulants: the higher the INR, the higher the risk of
bleeding
 STEMI cardiac care
• STEP 2: Determine preferred reperfusion strategy

Fibrinolysis preferred if: PCI preferred if:

 <3 hours from onset
 PCI not available/delayed
 door to balloon > 90min
 door to balloon minus
door to needle > 1hr
 Door to needle goal <30min
 No contraindications
 PCI available
 Door to balloon < 90min
 Door to balloon minus
door to needle < 1hr
 Fibrinolysis
contraindications
 Late Presentation > 3 hr
 High risk STEMI
 Killup 3 or higher
 STEMI dx in doubt
 Medical Therapy
MONA + BAH
• Morphine
• Analgesia
• Reduce pain/anxiety—decrease sympathetic tone,
systemic vascular resistance and oxygen demand
• Careful with hypotension, hypovolemia, respiratory
depression

• Oxygen (2-4 liters/minute)

• Up to 70% of ACS patient demonstrate hypoxemia
• May limit ischemic myocardial damage by increasing
oxygen delivery/reduce ST elevation
• Nitroglycerin
• Analgesia—titrate infusion to keep patient pain free
• Dilates coronary vessels—increase blood flow
• Reduces systemic vascular resistance and preload
• Careful with recent ED meds, hypotension, bradycardia,
tachycardia, RV infarction

• Aspirin (160-325mg chewed & swallowed)

• Irreversible inhibition of platelet aggregation
• Stabilize plaque and arrest thrombus
• Reduce mortality in patients with STEMI
• Careful with active PUD, hypersensitivity, bleeding
disorders
• Beta-Blockers (class I, level A)
• 14% reduction in mortality risk at 7 days at 23% long
term mortality reduction in STEMI
• Approximate 13% reduction in risk of progression to MI
in patients with threatening or evolving MI symptoms
• Be aware of contraindications (CHF, Heart block,
Hypotension)
• Reassess for therapy as contraindications resolve

• ACE-Inhibitors / ARB (class I, level A)

• Start in patients with anterior MI, pulmonary
congestion, LVEF < 40% in absence of
contraindication/hypotension
• Start in first 24 hours
• ARB as substitute for patients unable to use ACE-I
• Heparin
– LMWH or UFH (max 4000u bolus, 1000u/hr)
• Indirect inhibitor of thrombin
• less supporting evidence of benefit in era of reperfusion
• Adjunct to surgical revascularization and thrombolytic /
PCI reperfusion
• 24-48 hours of treatment
• Coordinate with PCI team (UFH preferred)
• Used in combo with aspirin and/or other platelet
inhibitors
• Changing from one to the other not recommended
 Additional medication therapy
• Clopidogrel (class I, level B)
• Irreversible inhibition of platelet aggregation
• Used in support of cath / PCI intervention or if
unable to take aspirin
• 3 to 12 month duration depending on scenario

• Glycoprotein IIb/IIIa inhibitors

(class IIa, level B)
• Inhibition of platelet aggregation at final common
pathway
• In support of PCI intervention as early as possible
prior to PCI
 Additional medication therapy

• Aldosterone blockers (class I, level A)

– Post-STEMI patients
• no significant renal failure (cr < 2.5 men or 2.0 for
women)
• No hyperkalemis > 5.0
• LVEF < 40%
• Symptomatic CHF or DM
 Rekomendasi pengobatan SKA
• Rekomendasi terapi antitrombotik tanpa terapi
reperfusi
• Rekomendasi terapi antirombotik pada pemberian
terapi fibrinolitik
• Rekomendasi antitrombotik pada terapi angioplasti
koroner perkutan (PCI) primer
• Dosis ACE-Inhibitor pada tatalaksana SKA
• Dosis ARB pada SKA
• Rekomendasi terapi untuk mengatasi nyeri, sesak
dan anxietas
 STEMI care CCU
• Monitor for complications:
• recurrent ischemia, cardiogenic shock, ICH, arrhythmias

• Review guidelines for specific management of

complications & other specific clinical
scenarios
• PCI after fibrinolysis, emergent CABG, etc…

• Decision making for risk stratification at

hospital discharge and/or need for CABG
 Risk Stratification to Determine the Likelihood of
Acute Coronary Syndrome
Assessment Findings indicating HIGH Findings indicating Findings indicating LOW
likelihood of ACS INTERMEDIATE likelihood of ACS in
likelihood of ACS in absence of high- or
absence of high-likelihood intermediate-likelihood
findings findings
History Chest or left arm pain or Chest or left arm pain or Probable ischemic
discomfort as chief discomfort as chief symptoms
symptom symptom Recent cocaine use
Reproduction of previous Age > 50 years
documented angina
Known history of coronary
artery disease, including
myocardial infarction
Physical New transient mitral Extracardiac vascular Chest discomfort
regurgitation, disease reproduced by palpation
examination hypotension, diaphoresis,
pulmonary edema or rales

ECG New or presumably new Fixed Q waves T-wave flattening or

transient ST-segment Abnormal ST segments or inversion of T waves in
deviation (> 0.05 mV) or T- T waves not documented leads with dominant R
wave inversion (> 0.2 mV) to be new waves
with symptoms Normal ECG
Serum cardiac Elevated cardiac troponin Normal Normal
T or I, or elevated CK-MB
markers
 ACS risk criteria
Low Risk ACS Intermediate Risk
No intermediate or high
ACS
risk factors Moderate to high likelihood
of CAD
<10 minutes rest pain
>10 minutes rest pain,
Non-diagnositic ECG now resolved

Non-elevated cardiac T-wave inversion > 2mm

markers
Slightly elevated cardiac
Age < 70 years markers
 High Risk ACS
Elevated cardiac markers
New or presumed new ST depression
Recurrent ischemia despite therapy
Recurrent ischemia with heart failure
High risk findings on non-invasive stress test
Depressed systolic left ventricular function
Hemodynamic instability
Sustained Ventricular tachycardia
PCI with 6 months
Prior Bypass surgery
 Low Intermediate High
risk risk risk

Chest Pain
center
Conservative Invasive
therapy therapy
 Secondary Prevention
• Disease
– HTN, DM

• Behavioral
– smoking, diet, physical activity, weight

• Cognitive
– Education, cardiac rehab program
 Secondary Prevention
disease management
• Blood Pressure
– Goals < 140/90 or <130/80 in DM /CKD
– Maximize use of beta-blockers & ACE-I
• Lipids
– LDL < 100 (70) ; TG < 200
– Maximize use of statins; consider fibrates/niacin
first line for TG>500; consider omega-3 fatty acids

• Diabetes
– A1c < 7%
 Secondary prevention
behavioral intervention
• Smoking cessation
– Cessation-class, meds, counseling
• Physical Activity
– Goal 30 - 60 minutes daily
– Risk assessment prior to initiation
• Diet
– DASH diet, fiber, omega-3 fatty acids
– <7% total calories from saturated fats
 Secondary prevention
cognitive
• Patient education
– In-hospital – discharge –outpatient clinic/rehab

• Monitor psychosocial impact

– Depression/anxiety assessment & treatment
– Social support system
 Medication Checklist
after ACS
• Antiplatelet agent
– Aspirin* and/or Clopidorgrel
• Lipid lowering agent
– Statin*
– Fibrate / Niacin / Omega-3
• Antihypertensive agent
– Beta blocker*
– ACE-I*/ARB
– Aldactone (as appropriate)
 Summary
• ACS includes UA, NSTEMI, and STEMI
• Management guideline focus
– Immediate assessment/intervention (MONA+BAH)
– Risk stratification (UA/NSTEMI vs. STEMI)
– RAPID reperfusion for STEMI (PCI vs. Thrombolytics)
– Conservative vs Invasive therapy for UA/NSTEMI
• Aggressive attention to secondary prevention
initiatives for ACS patients
• Beta blocker, ASA, ACE-I, Statin
 Conclusions; Treatment of
NSTEMI/USA
• ASA
• NTG (consider MSO4 if pain not relieved)
• Beta Blocker
• Heparin/LMWH
• ACE-I
• +/- Statin
• +/- Clopidogrel (don’t give if CABG is a possibility)
• +/- IIBIIIA inhibitors (based on TIMI risk score)
 Conclusions; Treatment of STEMI
• ASA
• NTG (consider MSO4 if pain not relieved)
• Beta Blocker
• Heparin/LMWH
• ACE-I
• +/-Clopidogrel (based on possibility of CABG)
• IIB-IIIA
• +/- Statin
• Activate the Cath Lab!!!